Individual
DERRELL GLENN JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
436 CLAREMONT CT, SUITE 100, COLONIAL HEIGHTS, VA 23834-1765
(804) 526-2121
(804) 520-2617
Mailing address
205 MISTY RIDGE LN, SUFFOLK, VA 23434-1516
(757) 406-7328
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0110002804
VA
363AM0700X
Medical Physician Assistant
0110002804
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10040880P
OPTIMA
VA
05
—
1104072297
—
VA
01
—
P00685057
RR MEDICARE
VA
Enumeration date
08/08/2008
Last updated
05/26/2010
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